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APPLICATION FOR SANITATION PERMIT Permit No. t?_ 5 (Complete in Duplicate) Date Issued Applica}ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOBADDRESS AND LOCATION-----------------------------------------------------------------------------------......---------.--. -----•••------------------ ------..----------------------- Owner's Name----------- --------- ---------•-6---------- -- ------------------------- Address-----------------------•--•-------�1 --------6�--'--------- ------ ---------.-...1 -�-- ------- ----------------------•-----_--------------- Contractor's Name--------------------------------------------------------------------------------------------------------------------------------------------- Phone:----_.--------•---------------- Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms.- Number of baths _1___ Lot size -_-- ----------------_________ Water Supply: Public system ❑ Community system ❑ Private +h to Water Table &_eft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No Construction: Yes ❑ No !❑`� TYPE OF INSTALLATION AND SPECIFICATIONS: " (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material_-___----- _______-____-.---___--___________- ❑ No. of compartments- ------------------------Size-------------------------------Liquid dept.------------------------Capacity_----------------- � Disposal Field: Distance from nearest well----S.._'-_Distance from foundation----k-----------Distance to nearest lot linp__j 6_., Number of lines----------4."/ Length of each line--------- --_ �_ __.-.Width of trench___ 6--7------------------ Type of filter material_Z---9_____2------Depth of filter material____ -_____Total length------- - ---------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-----------_........Distance to nearest lot line_-___-_-__-__.__ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation.-.-----------------Lining material________..____-.___________________- r d ❑ Size:.Diamefers,_.------------------------=--------Depth-----------•_------------------------- -------------Liquid Capacity----------------------------gals. 0 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ rn ❑ Distance to nearest lot line-------- --------------------------------------•-------------------------------------------------------------------------------------------- _Remodel_i_n g and/or nd 3or repairing e airin9 ri�beI ------------- � G�d _ - -A-._•'41___-..A-.-._____ _____-___._______________._-_____________--------------------------------------------------------------_----------------------- ------------------------------------------.____.-______________.___-.______________-.-.____.--..__________-----•__________-.---________-__•_•-___-________.__.-___------______-__-_________________-_____----__--_____-_ ____________________________ ___________________•---__________________--_______--__---_________--_____-._-_.____________-__-________-.--_________--_______-_________-___________-___--______________ _ I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ' - Owner (Signed ---------- ---------------------------------------------------- ------ - By:------- •--------------------------------------------------- --•-------------------------------------------------------------------(Title)--•----------------•-----•-•-- ------------------ I T ---------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___________ __ _ ___ '_- --- ----- -- -----Q--��------- •---- DATE------------------------------- ----- ----------- REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------• DATE--------------------------------------------_------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------_ DATE--------------------------------------------- -------------- Alterationsand/or recommendations:------------------------------------------------- •--•---------------------------•-•------------------------------------------------------------------------- --------------------------- ---------------- ---------•---------- -------------•---------------------------- ------------------ -------•--------------------- ---•- •-------------..---• -------•-•----------------------------------------------•-- ------------------------------•---•------------- -----•------- •-------------- •------------------------ - --- ---•----------------•---------------------------- -- � ------- ----------------.._..----•-------------Date.---- - •-.--------- ---- ---------- -•- - --•------------------••-----•• ��---„. FINAL INSPECTIO ----------•------------------------- - -- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; Revised W-2100